The 24Th Conference on Priorities in Perinatal Care in South Africa Was Held Under The

The 24th Conference on Priorities in Perinatal Care in South Africa was held under the auspices of the Priorities in Perinatal Care Association and sponsored by Abbott Laboratories SA (Pty) Ltd

Editor’s Note:

The articles included in these Proceedings were, mostly, received electronically and have been included as submitted by the presenter/author. Faxed articles have been retyped.

Some articles have been shortened.

Abstracts were included where articles were not submitted.

References are available from the authors.

Articles have not been included for presentations, which were withdrawn and not presented at Priorities.

INDEX

THE VALUE OF AN ONGOING AUDIT OF KANGAROO MOTHER CARE IN IMPROVING CLINICAL PRACTICE. E van Rooyen 1

COSTING OF OUTREACH STRATEGIES FOR IMPLEMENTING NEW HEALTH CARE INTERVENTIONS – THE CASE OF KANGAROO MOTHER CARE. A-M Bergh 7

THE ILLNESS PROFILE DURING THE FIRST YEAR OF LIFE OF VERY LOW BIRTH WEIGHT INFANTS DISCHARGED FROM A KANGAROO MOTHER CARE UNIT.

GF Kirsten 12

LIMPOPO INITIATIVE FOR NEWBORN CARE (LINC): MAJOR ACHIEVEMENTS.

PL Mashao 15

THE ROLE OF THE ENROLLED NURSES AND ENROLLED AUXILIARY NURSES IN THE IMPLEMENTATION OF THE LIMPOPO INITIATIVE FOR NEWBORN CARE.

NC Mzolo 19

IS ACCREDITATION OF EXCELLENT NEWBORN CARE POSSIBLE? AF Malan 25

EVALUATION OF HOSPITALS FOR NEWBORN CARE IN LIMPOPO PROVINCE.

DH Greenfield 28

INTRODUCTION TO LIMPOPO INITIATIVE FOR NEWBORN CARE. A Robertson 32

PARENTAL INVOLVEMENT IN NEONATAL ICU. (Abstract) Martha Lekalakala 35

THE PROMOTION OF KANGAROO MOTHER CARE IN SOUTH AFRICA. L Goosen 36

CENTERING PREGNANCY®-IS IT FEASIBLE IN SOUTH AFRICA? E de Gouveia 38

“SERVICES OF SHAME”: WOMEN’S TESTIMONIES ON WHY ARE MATERNITY SERVICES INACCESSIBLE - A HUMAN RIGHTS ANALYSIS. N Mbombo 42

MEDICAL STUDENTS DURING THEIR OBSTETRIC TRAINING USE MIDWIVES AND DOCTORS AS ROLE MODELS. IS THIS A PROBLEM? G Draper 50

CLINICAL DECISION MAKING IN LABOUR FOR SAFER BIRTH. S Clow 57

SECRECY IN SOUTH AFRICA: FACTORS AFFECTING A PREGNANT WOMAN’S ABILITY TO DISCLOSE HER HIV+ STATUS. J Makin 63

THE STIGMA THE COMMUNITY ATTACHES TO HIV/AIDS. J Makin 67

THE PMTCT PROGRAM IN THE WESTERN CAPE PROVINCE OF SOUTH AFRICA: CHANGES AND CHALLENGES. Beverly Draper 73

VALIDITY OF A CLINICAL SCREENING TOOL AND TOTAL LYMPHOCYTE COUNT (TLC) TO DETERMINE ADVANCED HIV DISEASE IN PREGNANT WOMEN. (Abstract) M Besser 77

THE PREVALENCE OF CHORIO-AMNIONITIS AND CONGENITAL BACTERIAL INFECTION IN WOMEN AND THEIR INFANTS WHO DELIVERED BEFORE 34 WEEKS AND WHO RECEIVED ANTENATAL STEROIDS OR NOT. (Abstract) GF Kirsten 78

CULTURE-PROVEN SEPSIS DUE TO GRAM-NEGATIVE BACTERIA IN NEONATES: BACTERIA SPECIES AND THEIR CASE FATALITY RATES. S Velaphi 79

HIV SEROCONVERSION DURING PREGNANCY IN THE TYGERBERG REGION OF CAPE TOWN. GB Theron 82

A PROGRAMME TO INITIATE AND SUSTAIN BREAST MILK FEEDING IN VERY LOW BIRTH WEIGHT INFANTS IN A PRIVATE HOSPITAL NICU. L Herbst 85

THE USE OF nCPAP FOR VENTILATORY SUPPORT OF INFANTS TREATED IN A PRIVATE HOSPITAL NICU. A Toma 88

THE PREVALENCE OF RETINOPATHY OF PREMATURITY IN VERY LOW BIRTH WEIGHT INFANTS VENTILATED IN A PRIVATE HOSPITAL NEONATAL ICU.

I Steyn 90

A PLEA FOR ELECTRONIC FETAL HEART RATE MONITORING AT DISTRICT HOSPITALS AND MIDWIFE OBSTETRIC UNITS IN SOUTH AFRICA.

HJ Odendaal 94

RUPTURE OF THE UTERUS IN DURBAN IN THE NEW MILLENIUM: WHY IS IT STILL HAPPENING? NF Moran 97

IS A CAESAREAN SECTION RATE OF 50% TOO HIGH FOR A SECONDARY TEACHING HOSPITAL? AN AUDIT DONE AT THE PELONOMI HOSPITAL, BLOEMFONTEIN, SOUTH AFRICA. JM du Plessis 103

AMNIOINFUSION FOR MECONIUM-STAINED LIQUOR: A RANDOMIZED TRIAL.

M Singata 107

THE ASSOCIATION BETWEEN CHLAMYDIA TRACHOMATIS, MYCOPLASMA HOMINIS AND SPONTANEOUS PRETERM LABOUR. HJ Odendaal 110

LOW DOSE ORAL MISOPROSTOL FOR INDUCTION OF LABOUR AT KALAFONG HOSPITAL: WHAT FACTORS PREDICT SUCCESSFUL VAGINAL DELIVERY WITHIN 24 HRS? AM Mbele 114

NON-SUPINE, KNEE-CHEST POSTURE FOR DELIVERY: A RANDOMISED TRIAL.

S Ferreira 120

PROTOCOL FOR POST OPERATIVE NURSING CARE IN A POST NATAL UNIT. (Abstract) DR Kgoebane 130

OVERCOMING PITFALLS IN IMPLEMENTING THE VACCA OMNICUP SYSTEM FOR USE IN A BUSY LABOUR WARD. E Farrell 131

THE EARLY LYMPHOCYTE COUNT PREDICTS THE DEVELOPMENT OF BRONCHOPULMONARY DYSPLASIA. Karen Ferreira 133

THE PROFILE AND OUTCOME ON DISCHARGE OF INFANTS <1250G TREATED AT TYGERBERG CHILDREN’S HOSPITAL DURING 1994 AND 2004. JI van Zyl 137

NEONATAL ADMISSIONS AND THEIR OUTCOMES AT THE DR GEORGE MUKHARI HOSPITAL. (Abstract). TJ Mashamba 142

IMPROVING SURVIVAL RATES OF NEWBORN INFANTS IN SOUTH AFRICA.

D Woods 143

REDUCING MORTALITY & MORBIDITY IN NEONATAL CARE. A Blunden 146

PARENTING YOUR PREMATURE BABY. Welma Lubbe 151

SANITSA: SOUTH AFRICAN NEONATE, INFANT AND TODDLER SUPPORT ASSOCIATION. Welma Lubbe 156

OBSTETRIC CARE IN THE THREE RURAL REGIONS OF THE WESTERN CAPE.

HJ Odendaal 159

THE PERINATAL PROBLEM IDENTIFICATION PROGRAM V2 – A PERINATAL DEATH AUDIT TOOL. Johan Coetzee 165

THE PERINATAL PROBLEM IDENTIFICATION PROGRAMME (PPIP) IN THE WESTERN CAPE: FINDINGS AND IMPLICATIONS FOR SERVICE PROVISION. D Greenfield 169

FROM RESEARCH TO IMPLEMENTATION: FACING THE CHALLENGES (IMPLEMENTING THE FINDINGS OF THE WCP PPIP REPORT JULY 2003 – JUNE 2004). EL Arends 173

UNDER FIVE MORTALITY IN SOUTH AFRICAN HOSPITALS. ME Patrick 176

PERINATAL TRAINING PROGRAMMES. Melvina Petersen 180

BETTER BIRTHS INITIATIVE – THE WESTERN CAPE ROLL-OUT. EL Arends 185

HEALTH CARE ATTENDANCE PATTERNS BY PREGNANT WOMEN IN DURBAN, SOUTH AFRICA. (Abstract) S Sibeko 187

CALCIUM SUPPLEMENTATION TO PREVENT PRE-ECLAMPSIA: SYSTEMATIC REVIEW AND EXPLORATION OF DISCORDANT TRIAL RESULTS. Justus Hofmeyr 188

HEALTH PROMOTION FOR PREGNANT WOMEN - LIVED EXPERIENCES AND APPLICATION OF HEALTH PROMOTION MESSAGES IN A RURAL FARMING DISTRICT. Roberta Gordon 192

USING ACTION RESEARCH TO DEVELOP A WOMEN'S PERSONALISED HEALTH HANDBOOK IN THE WESTERN CAPE. Kirstie Rendall-Mkosi 196

EVALUATION OF A STRICT PROTOCOL APPROACH IN MANAGING WOMEN WITH SEVERE DISEASE DUE TO HYPERTENSION IN PREGNANCY: AN AUDIT OF CURRENT PRACTICE. Hennie Lombaard 201

SEXUAL ACTIVITY IN PREGNANCY. (Abstract) F Mkhize 211

EUROPEAN RESEARCH FUNDING FOR INTERNATIONAL COOPERATION IN HEALTH RESEARCH: THE INCO PROGRAMME. (Abstract). Albrecht Jahn 212

COMPARING ANC POLICIES ACROSS THREE AFRICAN COUNTRIES. J. Barniol 213

METHODOLOGICAL ASPECTS OF QUALITY MATERNITY CARE PROJECT.

R Mpembeni 218

TRAINING OF MATERNITY CARE PROVIDERS IN A REGIONAL HOSPITAL: IMPACT ON DELIVERY CARE PRACTISES AND DATA UTILIZATION. SN Massawe 223

COMMUNITY-BASED SAFE MOTHERHOOD IN TANZANIA. Declare Mushi 229

QUALITY OF MATERNAL CARE IN SOUTH AFRICA: WHERE DO WE REALLY STAND? LS Thomas 234

REGISTERING DELIVERY CARE IN CAPE VERDE. A NEW INSTRUMENT FOR REPORTING AND QUALITY IMPROVEMENT. (Abstract) Pitt Reitmaier 238

A TRI-NATION EFFORT TO INFLUENCE MATERNAL HEALTH POLICY: DID WE OR DIDN’T WE? LS Thomas 239

THE VALUE OF AN ONGOING AUDIT OF KANGAROO MOTHER CARE IN IMPROVING CLINICAL PRACTICE

Elise van Rooyen

Department of Paediatrics, Kalafong Hospital, MRC Research Unit for Maternal and Infant Health Care Strategies, University of Pretoria

Background

A 20-bed Kangaroo Mother Care (KMC) unit was established at Kalafong Hospital, Pretoria in July 1999. Continuous and intermittent KMC as well as conventional care is practiced in the unit on occasion when the mother is not able to lodge with her infant. All discharged infants were followed up at a weekly clinic, which is held in the unit.

Objective

The objective of the presentation was to discuss the importance of keeping accurate records regarding the practice of KMC and to present the results of data collected over a 5-year period as well as to discuss the value of the audit in improving clinical practice.

Method

All patients admitted to the KMC unit from 1 August 1999 to 31 July 2004 was included in the audit. A data sheet was completed for each admission. The data sheet was developed to keep accurate records of the patients cared for in the KMC unit. Data captured on the sheet included the following: birth, admission and discharge dates, birth, admission & discharge weights, gestational age of the infants, transfer dates out of the unit due to apnoea or infection, feeding practices, number of infants on oxygen and the time period that they received oxygen, number of deaths and follow-up clinic attendances.

The data was captured on the computer in Microsoft Excel and analysed each year.

Results

A total of 1885 infants were admitted to the KMC unit during the 5 years. Details of the total admissions, admissions per month, average length of stay in days and the bed occupancy in the unit is summarised in Table 1. When looking at the length of stay the longest period that a patient stayed in the unit was 165 days. The reason for the long stay was because the infant was oxygen dependent and could not be discharged on oxygen.

Table 1

Year

/ 1 / 2 / 3 / 4 / 5 / Total
Number of infants admitted / 319 / 361 / 369 / 428 / *408 / 1885
Average admissions / month / 27 / 30 / 31 / 36 / 34 / 31
Average length of stay in days / 13 / 14 / 14 / 13 / 12 / 14
Bed occupancy rate / 58% / 68% / 73% / 75% / 85% / 72%

*A ten-bedded cubicle was closed for 3 months due to repairs to the roof

The infants admitted to the unit were allocated to different weight categories according to their admission weight. This is portrayed in Chart 1. Overall 47% (883) infants admitted to the unit weighed less than 1501 grams.

Before implementation of KMC, infants were discharged at a weight of more than 1750 grams. After implementation of KMC 52% (970) infants were discharged from the unit weighing less than 1751 grams (Chart 2). In Table 2 the percentage of infants discharged at different weight categories is presented. More infants could be accommodated in the unit because it was possible to discharge infants at lower weights and thus sooner. Forty two percent of infants were discharged weighing less than 1701 grams.

Admission Weight Categories

Chart 1 Chart 2

Table 2

Discharge Weight Categories

Year

Total

1500g

1500 > 1600g

203

1600 > 1700g

114

113

121

144

537

1700 > 1800g

115

421

42% infants discharged with weight 1700g

64 % infants discharged with weight 1800g

Of the 1885 infants admitted to the KMC unit, 16 (0,8%) infants died in the unit or within 24 hours of being transferred back to the intensive care unit (ICU). (Table 3) Hundred and sixteen (6%) infants were sent back to the high care unit (HCU) due to apnoea or possible infection. Sixty infants had to be readmitted from home because they did not have satisfactory weight gain or because they lost weight.

Table 3

Deaths, Transfers and Readmissions

Year / 1 / 2 / 3 / 4 / 5 /

Total

Number of patients admitted / 319 / 351 / 369 / 428 / 408 / 1885
Infants that died in the unit / 0 / 3 / 5 / 4 / 4 / *16 (0,8%)
Infants T/F back to HCU with apnoea / possible infection / 25 / 24 / 17 / 22 / 28 / 116 (6%)
Infants readmitted from home / 5 / 18 / 12 / 19 / 6 / # 60 (3%)

*6 expected deaths - (trisomy 18, spina bifuda, microcephaly, AIDS, prune belly, PDA)

*10 unexpected deaths

*1 death associated with maternal depression

#47% infants readmitted from home during winter months

If the deaths that occurred are analysed it was found that there were 6 expected deaths and 10 unexpected deaths. (Table 3) One of the unexpected deaths occurred in a mother and infant pair where the mother was severely depressed. Due to her depression and poor response to communication it was only in retrospect that it was realised that the mother also had psychiatric problems. From this incident we realised that it is very risky to expect a mother to be the primary care taker of her premature infant if she has a severe depression or suffers from a psychological problem. Mothers who show signs of mental health problems are therefore excluded from the KMC unit and their infants receive conventional neonatal care.

Characteristics of infants that died are summarised in table 4. In order to see whether the infant deaths had a seasonal variation the data was analysed to see when the deaths occurred. Eighty one percent of infant deaths occurred during the winter months, April to September and 44% deaths occurred during the months April and May. Each year 60% of the nursing staff in the wards change and this staff change occurs at the beginning of April each year. The high percentage of infant deaths during this period may be due to the lack of proper orientation in the Kangaroo Mother Care method and training in neonatal resuscitation methods.

Infants were discharged much sooner and at a lower weight than in the past and it was therefore important to see how many infants did not have satisfactory weight gain of at least 10 grams per day. Infants who lost weight or did not gain weight was readmitted to the unit. Only 60 (3%) infants had to be readmitted during the 5-year period. (Table 3) In order to see whether the readmissions had a seasonal pattern, the data was analysed and it was found that 47% infants were readmitted during the winter months, April to September. Readmissions were not increased during the colder months compared to the warmer months. The main factors that played a roll in infants needing readmissions were mothers failing to practice KMC continuously.